JOURNAL OF MANUAL & MANIPULATIVE THERAPY

2023, VOL. 31, NO. 1, 4–12

https://doi.org/10.1080/10669817.2022.2065599

Neural mobilization in low back and radicular pain: a systematic review

Mica Peacock*, Samuel Douglas* and Preeti Nair
Samuel Merritt University, Department of Physical Therapy, Oakland, CA, USA

ABSTRACT KEYWORDS
Background: Low back pain can present with radicular pain caused by lumbosacral nerve root Neural mobilization; nerve
pathology. Neural mobilization (NM) is a treatment technique used to treat low back and root; low back pain; sciatica;
radicular pain (LBRP). radicular
Purpose: To evaluate the e(ectiveness of NM interventions in improving pain, disability, and
function in adults with LBRP.
Data Sources: CINAHL Plus, MEDLINE (Ovid), Physiotherapy Evidence Database, and Cochrane
databases were searched.
Study Selection: Randomized controlled trials assessing the e(ect of NM on pain, disability,
and/or function in adults with LBRP.
Data Extraction: Authors reviewed studies and used the PEDro scale and the revised Cochrane
risk-of-bias tool to assess methodological quality and risk of bias.
Data Synthesis: Eight studies were included. Six of the eight studies found the addition of NM
to conservative treatment improved all measured outcomes. One study found improvements
in some but not all functional measures, and delayed improvements in pain. One study found
improvements in measures of neural sensitivity, but not overall pain and disability.
Conclusions: NM may be an e(ective tool for short-term improvements in pain, function, and
disability associated with LBRP. Additional high quality research is needed.
Study registration: : This systematic review protocol was registered with PROSPERO (registra-
tion number: CRD42020192338).

Introduction
symptoms may also exist and include paresthesia,
Low Back and Radicular Pain (LBRP), de)ned as pain weakness, and diminished ankle and/or knee reqexes
due to compression, irritation, or other pathology of [9]. No single assessment serves as the gold standard
one or more lumbosacral nerve roots, is one of the for diagnosis of LBRP, so a medical diagnosis of LBRP is
most common forms of low back pain [1–3]. Annual therefore only reached after a combination of imaging
prevalence has been reported as high as 25% and studies, a detailed review of the patient’s symptoms,
lifetime prevalence as high as 43% [1,4]. Not only is and the performance of a physical examination[9].
LBRP common it is signi)cantly debilitating. Compared Given the variety of causative factors involved, range
to other forms of low back pain, LBRP is associated with of symptom presentation, and diBculty in reaching an
a variety of poor outcomes. These outcomes include accurate diagnosis, LBRP is a challenging condition to
more severe and persistent pain, increased cost of care, diagnose and treat.
and longer periods of disability and absence from work Treatment options for LBRP include conservative
[1,5–7]. Therefore there is a need to treat this promptly care, pharmaceutical interventions and surgery.
and e(ectively. Conservative care options are varied and may include
In terms of isolating the cause of pain, lumbar disc a variety of exercise protocols, electrical modalities
herniation is widely considered the most common such as transcutaneous electrical nerve stimulation,
cause of LBRP [8–10]. However, LBRP may also be and techniques aimed at mobilizing the a(ected tissue
caused by osteophytes, spondylolisthesis, and other such as spinal mobilization, and neural mobilization
local factors. Symptom presentation of LBRP usually (NM)[12].
involves pain characterized as sharp, burning, dull, Neural mobilization refers to the therapeutic prac-
aching or lancinating that radiates from the lower tice of applying mechanical forces to nerves in the
back below the gluteal fold and follows body, with the goal of restoring healthy movement.
a dermatomal distribution based on the level of spinal Nerves must be able to move within the nerve bed (i.e.
root pathology[11]. In addition to pain, other surrounding tissue) for normal movement to occur,

CONTACT Mica Peacock [email protected] Samuel Merritt University, Department of Physical Therapy, 3100 Telegraph Avenue
Oakland, Oakland, CA 94609, USA
The authors report no conflict of interest.
*Both authors contributed equally to this work and are co-first authors
Supplemental data for this article can be accessed here.
© 2022 Informa UK Limited, trading as Taylor & Francis Group
 JOURNAL OF MANUAL & MANIPULATIVE THERAPY 5

and tolerate strain, compression, and transverse move- limited our searches to randomized controlled trials
ment along the nerve bed[13]. Some NM techniques (RCTs) and excluded MEDLINE records. No )lters
directly mobilize the neural tissue (e.g. nerve glide, related to publication date were used for any of
nerve qossing) via either active (e.g. exercise) or pas- our searches, and no limitations on outcome mea-
sive (e.g. manual therapy) techniques[14]. Others indir- surement timeline were applied prospectively. See
ectly mobilize the nerves via movement of the Appendix 1 for an example search strategy.
surrounding tissues (e.g. spinal mobilization)[15].
NM may be helpful for decreasing pain and
Eligibility criteria
restoring nerve function in a variety of musculos-
keletal conditions, but its e(ects on LBRP are not RCTs, available in English, assessing the e(ect of NM
well-studied[16–21]. A 2014 critical review by on pain, function, or disability in adults with LBRP
Efstathiou et al [22] concluded that the existing were eligible for inclusion.
literature was too sparse and low-quality in deter- Included studies met the following criteria: (1)
mining the e(ectiveness of treating lumbar radi- Participant populations presented with symptoms,
culopathy with NM. More recently, a 2016 radiological )ndings, or other clinical )ndings of
systematic review by Su and Lim [23] found that LBRP. These included radiological )ndings of lumbar
NM interventions provided pain relief and reduc- disc herniation or degeneration, back pain radiating
tion in disability for people with nerve-related down into at least one lower extremity, reproduc-
chronic musculoskeletal disorders, but found no tion of symptoms with passive straight leg raise
signi)cant di(erences between NM and other con- (PSLR) or slump test, myotomal weakness, dermato-
servative treatments. Finally, a 2017 systematic mal change in sensation, or hyporeqexia in
review by Basson et al [14] on the eBcacy of a lumbosacral innervation pattern. (2) NM interven-
treating various musculoskeletal conditions with tion was provided using methods that directly
NM found that a variety of NM techniques can mobilize the neural tissue (e.g. nerve glide, nerve
improve pain and disability in these participants. qossing) via either active (e.g. exercise) or passive
Given the lack of consensus on the functional (e.g. manual therapy) techniques. Eligible compara-
e(ects of NM on LBRP, this )eld of research would tor/control conditions included no treatment, sham
bene)t from a systematic review focused solely on treatment, or conservative treatment not involving
a population with lumbar radicular pain. The objec- neural mobilization. (3) Outcomes assessed at least
tive of this systematic review was to evaluate the one of our primary outcomes of interest (pain, dis-
e(ectiveness of NM interventions in improving pain, ability, and function), via scales such as the Numeric
disability, and function in adults with LBRP. Pain Rating Scale (NPRS), Visual Analog Scale (VAS),
Oswestry Disability Index (ODI), Roland-Morris
Disability Questionnaire (RMDQ), or the Short Form
Methods Health Survey (SF-36 or SF-12).
Study registration Animal studies, case reports, cohort studies, and
studies on healthy participants were excluded.
Study registration: This systematic review protocol Studies with patient populations including evidence
was registered with PROSPERO (registration number: or indication of speci)c spinal pathology (including
CRD42020192338), and was performed in line with the but not limited to vertebral fracture, neoplasm, cauda
PRISMA declaration guidelines. equina syndrome, and spinal infection), systemic neu-
rological disorders or lesions, or low back pain without
radicular qualities were also excluded. Studies compar-
Search strategy
ing two separate interventions with no control condi-
The databases searched in this systematic review tion were excluded, as were studies assessing NM only
were CINAHL Plus, MEDLINE (Ovid), Physiotherapy performed by indirect mobilization of the nerves via
Evidence Database, and Cochrane Central Register movement of the surrounding tissues (e.g. spinal
of Controlled Trials. All searches were performed in mobilization).
May 2020. Our search strategy targeted clinical trials Two reviewers (SD and MP) independently
with two primary variables of interest, a speci)c screened titles and abstracts of records identi)ed
participant population (people with LBRP) and our via the described search strategy using these inclu-
speci)c intervention (neural mobilizations). Our sion and exclusion criteria. Full-text of appropriate
search strategy included terms related to LBRP, studies were screened independently for inclusion
including sciatica, neurogenic, and disc herniation, by both reviewers. Discrepancies were resolved by
as well as related terms for neural mobilization consensus meeting. In the case of continued dis-
interventions, including nerve modality, nerve ten- agreement, a third reviewer would have been used
sion, and nerve Oossing. For CINAHL Plus, we also to determine eligibility for inclusion.
6 M. PEACOCK ET AL.

Data extraction and quality assessment which the separate domains are combined to give an
overall assessment of each study’s risk of bias as ‘low risk’,
Data were systematically extracted from the
‘some concerns’, or ‘high risk’[26].
abstract and full-text of each study. The following
items were included: author name and year of pub-
lication, participant demographics, experimental Data synthesis and analysis
and control treatment protocols, all outcome para-
meters including assessment timing, and main To assess the appropriateness of performing a meta-
results. analysis, we compared the timeframe and method of
Articles that met the inclusion criteria were assessed outcome measurement in the eight included studies.
using the PEDro scale and the revised Cochrane risk-of- No more than two studies used the same combination
bias tool (RoB2). The PEDro scale is a valid and reliable of intervention, outcome measure, and assessment
tool for measuring the methodological quality of clinical timeframe, and we therefore concluded that meta-
trials[24]. The scale provides a rating for each study analysis was not appropriate.
between zero and ten based on a series of “yes or ‘no’
questions, with a score of >8 considered excellent, a score
Study selection
of 6 to 8 considered good, a score of 4 to 5 considered
fair, and a score of <4 considered poor[25]. The RoB2 is The database searches resulted in 704 records. After
a tool for assessing the risk of bias in randomized trials. removing duplicates and screening at title/abstract
Five separate domains of potential bias are assessed and and full-text levels, eight studies remained. Figure 1
scored as ‘low risk’, ‘some concerns’, or ‘high risk’, after shows a summary of the study selection process.

Figure 1. PRISMA flowchart.

 JOURNAL OF MANUAL & MANIPULATIVE THERAPY 7

Table 1. Demographics of Included Studies.

Intervention Group Control Group

sample age mean symptom duration sample age mean symptom duration
Study total sample size size (SD) mean (SD) size (SD) mean (SD)
Ahmed et al. 2013 n = 30: 14 female, 16 n = 15 53.0 (1.9) 4.87 (1.50) weeks n = 15 52.6 (1.6) 5.26 (1.75) weeks
male years years
Cleland et al. 2006 n = 30: 9 female, 21 n = 16 40.0 (12.2) 14.5 (8.0) weeks n = 14 39.4 (11.3) 18.5 (12.5) weeks
male years years
Ferreira et al. 2016 n = 60: 45 female, 15 n = 30 43.9 (14.5) 302.4 weeks n = 30 40.3 (12.9) 104.3 weeks
male years years
Jeong et al. 2016 n = 30: 14 female, 16 n = 15 35.1 (6.4) – n = 15 41.6 (11.1) –
male years years
Nagrale et al. 2013 n = 60: 39 female, 21 n = 30 38.2 (3.47) 66.31 (11.16) weeks n = 30 37.76 (4.70) 64.14 (7.78) weeks
male years years
Pallipamula & n = 42 n = 21 42.53 (6.99) 9.09 (1.89) weeks n = 21 40.2 (7.55) 8.91 (1.80) weeks
Singaravelan 2012 years years
Plaza-Manzano et al. n = 32: 16 female, 16 n = 16 45.4 (6.0) 75.2 (6.1) weeks n = 16 47.0 (8.0) 74.7 (6.5) weeks
2020 male years years
Satishkumar et al. 2017 n = 38 n = 19 34.11 (8.36) 32.02 (12.38) weeks n = 19 35.47 (8.40) 31.55 (11.12) weeks
years years
SD: standard deviation

Study characteristics The frequency of intervention and assessment

was highly variable between studies. The duration
Table 1 reports sample size, gender distribution, age, of the intervention ranged from six straight days of
and symptom duration for each study’s intervention intervention to six weeks of intervention three times
and control group. The studies included in this review per week. Four studies [28,32–34] included a home
involved a total of 322 participants. The six studies that exercise program in addition to in-person treatment
reported participant gender involved a total of 137 sessions. Four studies [27,29,32,34] assessed out-
female participants and 105 male participants. comes only at baseline and at the )nal treatment
Table 2 reports intervention details, outcome mea- session. Others included assessments at intermedi-
sures, frequency of intervention and assessment, and ate time points[31], at a follow-up after the end of
results of each of the eight included studies. treatment[28], or both [30,33].
Five of the eight studies [27–31] performed neuro- The populations captured by the inclusion and
dynamic slider techniques, two [32,33] performed exclusion criteria of the eight studies were also
a passive nerve stretch, and one [34] performed signi)cantly heterogeneous. Three studies [29–31]
a neurodynamic tensioner. A slider is a technique in required MRI con)rmation of lumbosacral disc her-
which multiple joints are moved to alternate tension niation for inclusion, while others used symptom-
and slack on opposing ends of a nerve tract, resulting based criteria including radiating pain and symptom
in a ‘qossing’ e(ect that maximizes neural excursion provocation with nerve tension tests. There was
while keeping tension relatively constant. A tensioner a notable lack of consensus regarding the level of
is a technique in which multiple joints are moved to neural sensitivity considered to be appropriate for
pull on a nerve tract from both ends, moving dynami- inclusion and NM intervention. Four papers had
cally between a position of low tension and a position inclusion criteria of reproduction of radiating symp-
of high tension. A static nerve stretch places a nerve toms with PSLR of 30–70 degrees [31,34], 40–70
tract in a position of tension and holds there for a set degrees[30], or >35 degrees[27], while two papers
duration with no movement. One study [28] further [32,33] excluded participants with a positive PSLR of
attempted to reduce pressure on the a(ected nerve <45 degrees. Duration of symptoms prior to the
roots by performing a foramen opening technique in start of intervention ranged from an average of
addition to the neurodynamic slider.Control interven- 4.87 weeks in one study to 5.8 years in another.
tions varied widely. Five of eight studies [30–34] pro-
vided an exercise program intended to improve
lumbar stability and motor control, alone or along Methodological quality
with lumbar spinal mobilization. Other control inter-
ventions included TENS, traction, and advice to remain Of the eight included trials, four were good quality via
active. All study participants in NM intervention groups the PEDro quality assessment [28,30,32,33], three were
received the control interventions in addition to the fair [27,29,31], and one was poor[34]. The RoB2 risk-of-
NM interventions. bias assessments corresponded well with the PEDro
 8
Table 2. Intervention Protocols, Outcome Measures, and Results of Included Studies.
Protocol Outcome Measures Results

M. PEACOCK ET AL.
OM timing (*
Frequency, denotes
Duration, OMs used (* denotes translated
Study Nerve Mobilization Treatment Control Group Treatment Sessions translated version) version) Significant findings Non-significant findings
Ahmed et al. passive neurodynamic slider in supine PSLR flexion or extension exercises, 3x/wk; 2 wks; 6 NPRS; SF-12 at baseline IG treatment favored for both
2013 position with bias to peroneal or tibial 30 min per day, 10 reps, 2–3 sets in-person after wk 3* outcomes
nerves; HEP with nerve flossing technique of 10 reps per exercise; TENS – treatments
along sciatic nerve tract, 100 Hz
for 30 minutes per session
Cleland et al. static slump stretch with overpressure in long 5-min exercise bike; grade III–IV 2x/wk; 3 wks; 6 ODI; NPRS; Location of at baseline IG treatment favored for all
2006 sitting; Daily HEP with same technique lumbar spine mobilizations; in-person symptoms (body after wk 3* outcomes
standardized exercise program treatments 18 chart)
targeting low back pain; HEP of HEP sessions
standardized exercise program
Ferreira et al. grade III lumbar foramen opening advice to remain active 2x/wk; 2 wks; 4 NPRS (leg and low at baseline IG treatment favored for PSFS No significant BG dizerences for ODI
2016 mobilizations; passive neurodynamic slider in-person back); ODI 2.0*; after wk 2* and GPE after 2 weeks; IG 2.0 and location of symptoms at
in sidelying; progressed to active treatments 14 PSFS; Location of after wk 4 treatment favored for leg any timepoints; No significant BG
neurodynamic slider in slump sitting; Daily HEP sessions symptoms (body NPRS, low back NPRS, PSFS, dizerences for leg or low back
HEP with sliding and tensioning techniques chart); GPE and GPE after 4 weeks NPRS after 2 weeks
Jeong et al. 2016 active neurodynamic tensioner in seated lumbar segmental stabilization 3x/wk; 6 wks; 18 SF-36 PF and GH at baseline IG treatment favored for both
position exercise program targeting treatments subscores after wk 6* outcomes
transversus abdominis and
multifidus
Nagrale et al. static slump stretch with overpressure in long 5-min exercise bike; grade III–IV 2x/wk; 3 wks; 6 NPRS; ODI; FABQ at baseline IG treatment favored for NPRS No significant BG dizerence for ODI
2013 sitting; Daily HEP with same technique lumbar spine mobilizations; in-person after wk 1 and FABQ after weeks 1 and after weeks 1 and 2
standardized exercise program treatments 18 after wk 2 2; IG treatment favored for
targeting low back pain HEP sessions after wk 3* all outcomes after weeks 3
after wk 6 and 6
Pallipamula & active neurodynamic slider in seated slump TENS along the area of symptoms; 1x daily; 6 days; VAS; Sciatica at baseline IG treatment favored for all
Singaravelan position mechanical lumbar traction 6 sessions of Bothersomeness after outcomes
2012 NM and TENS Scale; PSLR; Active 6 days*
3 sessions of Lumbar Flexion;
lumbar Modified ODI
traction
Plaza-Manzano passive neurodynamic slider in supine motor control exercise program 2x/wk; 4 wks; 8 NPRS; S-LANSS; RMDQ; at baseline IG treatment favored for No significant group*time
et al. 2020 targeting sciatic nerve targeting transversus abdominis treatments PSLR; PPT after 2 wks S-LANSS and SLR interactions for NPRS, RMDQ, and
and multifidus; HEP with same after 4 wks* PPT
exercises 2 months
after final
session
Satishkumar active neurodynamic slider in seated slump lumbar stabilization exercises, 5x/wk; 4 wks; 20 NPRS; RMDQ*; PSLR; at baseline IG treatment favored for all
et al. 2017 position progressed weekly treatments FABQ* after wk 1 outcomes after weeks 1, 2
after wk 2 and 4
after wk 4*
NPRS: Numeric Pain Rating Scale; Short Form Health Survey (SF-36 or SF-12); PF: physical functioning; GH: general health; ODI: Oswestry Disability Index; PSFS: Patient Specific Functional Scale; GPE: Global Perceived Ezect; FABQ: Fear
Avoidance Beliefs Questionnaire; VAS: Visual Analog Scale; PSLR: passive straight leg raise; S-LANSS: Leeds Assessment of Neuropathic Symptoms and Signs (self-report version); RMDQ: Roland-Morris Disability Questionnaire; TENS:
transcutaneous electrical nerve stimulation; SMD: standardized mean score dizerence; MD: mean dizerence; BG: between groups; IG: intervention group; CG: control group; CI: confidence internal; HEP: home exercise program; PPT:
pressure pain threshold
Table 3. PEDro and Cochrane Quality Assessment.
PEDro Cochrane

1 2 3 4 5 6 7 8 9 10 11 total score* Subscores Domains 1–5 Overall Risk

Ahmed et al. 2013 y y y y n n n n n y y 5/10 1: low risk 2: high risk 3: some concerns 4: high risk 5: some concerns high risk
Cleland et al. 2006 y y y y n n y y y y y 8/10 1: low risk 2: low risk 3: low risk 4: low risk 5: some concerns some concerns
Ferreira et al. 2016 y y y y n n y y y y y 8/10 1: low risk 2: low risk 3: some concerns 4: low risk 5: low risk some concerns
Jeong et al. 2016 y y n n n n n n n y y 3/10 1: some concerns 2: high risk 3: some risk 4: low risk 5: high risk high risk
Nagrale et al. 2013 y y y y n n y y y y y 8/10 1: low risk 2: low risk 3: low risk 4: low risk 5: some concerns some concerns
Pallipamula & Singaravelan 2012 y y n y n n n y n y y 5/10 1: some concerns 2: low risk 3: some concerns 4: high risk 5: some concerns high risk
Plaza-Manzano et al. 2020 y y y y n n y y y y y 8/10 1: low risk 2: low risk 3: low risk 4: low risk 5: some concerns some concerns

JOURNAL OF MANUAL & MANIPULATIVE THERAPY

Satishkumar et al. 2017 y y y y n n n n n y y 5/10 1: low risk 2: high risk 3: some risk 4: high risk 5: some concerns high risk
*criterion 1 not included

9
10 M. PEACOCK ET AL.

quality assessments, with the fair and poor quality [30] found signi)cant group*time interactions for the
papers judged to be high risk, and the four good PSLR and the Leeds Assessment of Neuropathic
quality studies judged to have some concerns. Symptoms and Signs (a measure of neuropathic
Quality assessment scores for all studies are available pain), but not for the NPRS or pressure pain threshold.
in Table 3.
No trials were able to blind the therapist to the
Discussion
intervention they were delivering. This reqects an
ongoing challenge in the )eld rather than a failing of The goal of this systematic review was to determine
these studies in particular. Several studies that per- the e(ectiveness of NM in treating adults with LBRP.
formed physical assessments as outcome measures This subset of low back pain patients experiences
did not specify whether the assessor was blinded to worse outcomes on average[1], but has been inconsis-
the intervention group. Only one paper [28] pre- tently de)ned pathologically in prior research, limiting
published their study design in order to allow assess- the ability to draw conclusions about e(ective treat-
ment of result reporting bias. ments. NM was chosen as the intervention of interest
because it has been shown to be e(ective in treating
nerve-related pain in other body regions[14], but evi-
Results
dence related to lumbosacral pain is limited.
Table 2 describes the results of each individual study Six of the eight RCTs included in this review found
included in this systematic review. All eight included that adding an NM intervention to a conservative treat-
studies measured disability or function as a primary ment plan improved all outcomes. The results of the
outcome. Four [28,29,32,33] used the standard, mod- remaining two papers favored NM treatment for some
i)ed, or revised version of the ODI, two [30,31] used the outcomes; Plaza-Manzano et al [30] found improve-
RMDQ, and one study each used the Patient Speci)c ments in measures of neural sensitivity, but not overall
Functional Scale (PSFS)[28], SF-12[27], and select sub- pain and disability, while Ferreira et al [28] found
scales of the SF-36[34]. Seven of the studies included improvements in some but not all functional measures,
pain as a primary outcome measure, with six [27,28,30– and delayed improvements in pain. Furthermore, no
33] using the 11-point NPRS. Only three studies studies found any evidence of NM treatment having
[28,30,33] re-assessed outcomes at a follow-up later a detrimental e(ect on any outcomes. Overall, the
than the )nal treatment session, and only one [30] collective results of these eight studies indicate that
assessed any outcomes later than six weeks following NM may be recommended for treatment of LBRP,
initial treatment. although data are still too limited to determine the
extent to which NM contributes to the e(ectiveness
of a multi-modal treatment plan.
Disability/Function
The low quality and inconsistent rigor of the
Five of the eight included studies found signi)cant included studies is a limitation of this review. Only
between-group di(erences favoring NM treatment for four of the eight included studies achieved a quality
all outcomes related to function or disability at all post- rating of good on the PEDro scale and a RoB2 risk
baseline measurements [27,29,31,32,34]. Of the remain- assessment lower than ‘high.’ Several studies failed to
ing three studies, Nagrale et al [33] found signi)cant include critical information such as the proportion of
between-group di(erences favoring NM treatment for randomized participants who completed the entire
the ODI after weeks 3 and 6. Ferreira et al [28] had study, and the details of the concealed allocation pro-
mixed results, with the PSFS showing signi)cant cess used for randomization. Ahmed et al [27] stated
between-group di(erences favoring NM treatment that participants were given a home exercise program
after week 2 and week 4, but no signi)cant di(erences but gave no information about the frequency with
for the ODI. Plaza-Manzano et al [30] found no signi)- which they performed it. Jeong et al [34] described
cant group*time interaction for the RMDQ. the steps of the NM technique performed, but gave
no indication of whether the technique was performed
for multiple repetitions within a treatment session, and
Pain
provided no rationale for their choice of the general
Of the seven studies that included at least one mea- health and physical functioning subscales of the SF-36
sure of pain, )ve found signi)cant between-group dif- as sole outcome measures.
ferences favoring NM treatment for all outcomes The substantial variability in intervention design,
related to function or disability at all post-baseline frequency, and duration, as well as symptom intensity
measurements [27,29,31–33]. Of the remaining two and duration in participant populations, limits our abil-
studies, Ferreira et al [28] found signi)cant between- ity to draw conclusions about the eBcacy of the use of
group di(erences favoring NM treatment after week 4 any speci)c NM protocol. Our conclusions regarding
in leg and low back NPRS scores. Plaza-Manzano et al long-term e(ects are also limited because only three
 JOURNAL OF MANUAL & MANIPULATIVE THERAPY 11

studies re-assessed outcomes after the )nal treatment Professor in the Department of Physical Therapy at Samuel
session. The breadth of positive )ndings when NM is Merritt University.
added to a wide variety of control interventions does
con)rm that NM can be an appropriate part of a multi-
modal treatment plan for people with LBRP. Disclosure statement
The lack of consensus regarding language to Authors report no conqict of interest.
describe LBRP limits the ability of researchers and clin-
icians to understand and discuss this unique population.
The term ‘sciatica,’ while easily recognized, is not anato- ORCID
mically descriptive. Its continued use to describe both
nerve root pathology and peripheral nerve involvement Preeti Nair http://orcid.org/0000-0002-1609-0050
conqates two very di(erent clinical presentations. The
use of the term ‘radicular’ is also inconsistent across
studies. The word’s literal meaning is ‘pertaining to the
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